The Philadelphia Department of Health says a possible fourth swine flu death is being investigated. This comes as cases of swine flu, the H1N1
virus, have started to decline in the city and all over the state of Pennsylvania. 216 people have been hospitalized in Philadelphia with the H1N1
flu, according to a new update from the Philadelphia Health Department. Nine percent have required treatment in intensive care. School age children
have been the largest group affected. Health officials say the cases have started to decline in the city and state, but they're still recommending
that people take precautions, like regularly washing their hands.

BEIJING, July 6 (Xinhua) -- The number of locally infected cases of the A/H1N1 flu in China is expected to exceed that of imported ones among newly
reported cases in the near future, a health ministry official said here Monday.

"As the total number of infected people increases, a cluster outbreak of A/H1N1 flu in communities is likely to happen at any time, and serious
cases or even fatalities are highly possible," said Liang Wannian, vice director of the emergency office under the Health Ministry, at a press
conference .

The Chinese mainland reported 1,040 A/H1N1 flu cases as of 6 p.m. Sunday, with no serious cases or fatalities so far. Among the infected, 758 were
"imported" cases, the ministry's figures showed.

With the rising number of cases, China will gradually adjust its prevention and control measures by stopping hospitalizing flu victims with minor
symptoms, he said.

Under the adjustment, people in close contact with the patients could be observed at home instead of being put in a specially reserved place for
quarantine, which was a common practice previously, according to the official.

The Ministry of Health would intensify prevention measures in schools and local communities to curb the virus spread, he said.

To reduce the possibility of mass infection, the Ministry of Education (MOE) had ordered schools across the country to conclude the term at an
early date as long as they finished their teaching schedule and exams.

"In Beijing, Shanghai, Fujian, Sichuan and Guangdong provinces, all campus activities usually held before each semester ends have been shortened,
even the graduation ceremony was simplified," an MOE official Liao Wenke said at the same press conference.

The earliest detections of clustering flu cases in the country were at schools. After the flu outbreak in a primary school in Beijing on July 3,
the school started its summer vacation a week ahead of schedul

The American College of Emergency Physicians (ACEP) recently released a plan to help emergency departments, first responders, and public health
departments manage a surge in pandemic flu cases that many experts predict will happen this fall.

The 16-page plan was produced under a contract with the US Department of Health and Human Services (HHS) office of the Assistant Secretary for
Preparedness and Response (ASPR) and its Emergency Care Coordination Center, ACEP said today in a press release. The document defines critical
capabilities and suggests ways to achieve them, ACEP said.

"While H1N1's virulence is not predictable, it is expected to be highly contagious and will place added strains on the emergency care system," said
Nicholas Jouriles, MD, president of the ACEP, in the statement.

He added that planning for a second wave will be successful only with cooperation between first responders and public health officials. The plan urges
local ACEP chapters to enlist support from state and local health directors, local emergency managers, and political leaders for emergency planning
efforts.

The main components of the plan, based on the federal template for managing biological threats, include situational awareness, protecting emergency
department infrastructure and personnel, preventing service disruptions, organizing a timely surge response, and recovering to the previous status.
Communications with local and state public health officials are crucial, and it's important to have agreements in place for the "triggers"
authorities will use to "stand down" the pandemic plan, according to the document.

One of ACEP's key planning assumptions is that large volumes of vaccine against the novel H1N1 virus probably won't be available until mid October
at the earliest and that the public won't be protected from infections until 2 weeks after a second injection.

As a result, if the second pandemic wave begins September, health officials may depend heavily on community mitigation strategies to slow the spread
of the virus. Emergency departments will still face a surge of patients, but interventions such as school closures will likely strain the department
workforces even further, the ACEP plan warns.

Social distancing measures will also affect critical infrastructure businesses and institutions, which may slow the flow of transportation and
supplies. Emergency planners shouldn't assume that antiviral medications will be effective for a virus that may have undergone selection pressure
between waves, the report notes.

"While the precise effects on emergency departments to function cannot be predicted with confidence, contingency plans should be made for a
challenging scenario," the plan states.

The nation's economic problems and the importance of staying on the job may add to the pressures to keep schools open, the planners wrote. News
reports of deaths in young people, an age-group currently bearing the brunt of illnesses, might fuel even more parents to seek medical care for their
children.

The plan includes 27 capabilities for emergency department response to a severe novel H1N1 outbreak, each with suggested steps and an outline for what
level of health or government group is responsible. For example, the plan covers personal protective equipment stockpiling, facility security, crowd
management, alternate locations for triage and screening, and configuring waiting rooms for social distancing, if possible.

Stephen Cantrill, MD, an emergency department physician in Denver and a member of ACEP's clinical policy committee, told CIDRAP News that the novel
influenza plan is also designed to raise awareness among emergency physicians. The potential burdens will be vast, he said, not only for keeping the
workforce functioning during the surge, but also keeping departments adequately supplied.

"There are so many vulnerabilities in the supply chain, where do you start?" he asked, adding that even departments that are well prepared might not
able to sustain their supplies.

The impact of the influenza pandemic on emergency departments will be affected greatly by how local public health officials craft their messages to
the public, Cantrill said. He said the US Centers for Disease Control and Prevention (CDC) has done a good job communicating flu facts to the public,
including details on when to seek medical care.

The above translation describes 18 confirmed fatalities in Santa Fe Province, including 15 deaths in Rosario, as of Sunday night (see updated map). A
national report which reported no deaths in Santa Fe last week has an updated number of 9 for Santa Fe, and 60 for the entire country, most of which
is from cases in adjacent Buenos Aires Province. The 60 confirmed cases is a marked increase from the 26 reported last week However, the 60 reported
cases do not include other recent fatalities cited in media reports which included 11 deaths in Corrientes, 5 deaths in Neuquen, and at least one
death in Tierra del Fuego, Jujuy, Cordoba, San Juan, Salta, La Pampa, Rio Negros, Entre Rios, and Santiago del Estero. The national totals do not
include any fatalities in the above provinces, raising concerns of a rapid rise in cases that has not been reported beyond the local media
reportwww.recombinomics.com...

The Health Ministry says it is a woman of 28 years of age who lived in the south of Bogota and had no official coverage of the health system.

According to authorities the woman arrived last Thursday with respiratory symptoms to a health center in the southwest of the capital, which created
suspicion in the medical staff of a possible case of the virus, was sent to a tertiary hospital.

The woman, in the following 24 hours, progressively worse until a severe breathing difficulty that ended last Friday with his life.

Following specific protocols, an autopsy was performed with the suspected presence of the virus and the results confirmed that the patient had the
virus.

In Bogota the first victim was 24 years and died on June 4, the second was a man of 28 years, who died on June 19.

Manuel Villamizar, secretary for health, confirmed that contacts of the deceased and those who were close to their environment, have been the subject
of an exhaustive and there are no risks for them.

118 numbers are affected by the new influenza in Colombia and three people dead
.

Health authorities in Costa Rica today, the third reported death due to infection with influenza A (H1N1) in the country.

The deceased was a man of 55 years who was hospitalized for three days in a hospital in San Jose on Monday and died as a result of complications
caused by the flu to pneumonia presented box.

The Ministry of Health explained that this person was a chronic smoker from 13 years, it suffered from a lung disease that made him vulnerable to
influenza A (H1N1).

The first death was reported on May 9 while the second victim was a woman of 36 years suffering from obesity who died on June 23 but was reported
days later.

The Minister of Health of Costa Rica, Maria Luisa Avila, told Xinhua that are under routine analysis of pneumonia in seriously ill patients, even
after his death, to determine whether they were infected with pandemic influenza.

So far a total of 229 reported cases of influenza A (H1N1) confirmed, while 77 other people remain cases "likely."

Avila explained that the figure so high is probably due to exhaustion of reagents needed to perform confirmations, but said that in coming days will
resume testing. Fin End

Spain now has 832 cases of H1N1. The Health Ministry says that includes grave cases in Catalonia, Madrid, and Andalucia. In Madrid, a boy of 8 and a
woman of 35 continue to be ill, although the woman is improving. In Andalucia, an American military person is in intensive care in Rota. Health
sources said he had a serious previous illness.

County health officials said Monday the woman, whose name was not released, died July 1 while she was hospitalized with severe pneumonia that was a
complication of swine flu, also known as the H1N1 viruswww.mercurynews.com...

BANGKOK (AP) -- Thailand has reported the deaths of two more people afflicted with swine flu, bringing the country's total to nine.

Deputy Public Health Minister Manit Nop-amornbodi said Tuesday the latest victims were a 58-year-old man at a Bangkok hospital and an 8-year-old girl
in the southwestern province of Phetchaburi. Both died on Monday.

He said that the man had kidney infection prior to contracting the virus that further weakened his immune system.

The ministry also reported 156 new cases, bringing the country's total to 2,428. Manit said 40 remained hospitalized, two in critical condition.

The NA sequence from the Hong Kong teenager with oseltamivir Tamiflu resistance, A/Hong Kong/2369/2009, has been released. The sequence is
clearly that of pandemic H1N1 and exactly matches (other than H274Y) the sequence of an earlier isolate A/New Jersey/1/2009. Similarly, the HA
sequence is also swine and has two recently acquired polymorphisms, one of which is also in New Jersey/1/2009. Thus this sequence is in circulation
and as was seen in the isolates in Denmark and Japan, the H274Y is appended onto a swine H1N1 background.

These results mimic that seen in seasonal flu, where H274Y was appended onto multiple seasonal flu background. The polymorphisms jumped from one
background to the next, via genetic hitchhiking and recombination. Thus like seasonal flu, the pandemic H1N1 has no evidence of reassortment. The
H274Y is on an evolutionarily fit H1N1 that will allow the H274Y to move about through the pandemic H1N1 gene pool. This movement will be facilitated
by widespread Tamiflu usage, which will select minor populations as happened in Denmark and Japan, where H274Y was identified in patients receiving a
maintenance dose of Tamiflu.

However, in Hong Kong, like the many examples of H274Y in H1N1 seasonal flu, the resistance is in patients not receiving Tamiflu. However, the
lessons of H274Y in seasonal flu were not learned. Recent comments have described H274Y acquisitions through random mutation and reassortment.
However, there has been no examples of recent seasonal H1N1 flu genes in the pandemic H1N1 sequences, and the H274Y in patients receiving Tamiflu
likely represent selection of a minor population with H274Y that is silently spread. The release of the sequences from Denmark and Japan would be
useful.
.

Swine Flu Returns With a
Vengeance www.myfoxhouston.com...
HOUSTON - Even though the panic seems to have faded, the number of swine flu cases has just jumped dramatically.

The Centers for Disease Control and Prevention says the most significant increase in reported U.S. activity came at the end of June, months after the
initial scare. U.S. deaths jumped 34 percent to 170 in just the past week.

"We don't have any evidence that it's mutated yet, but I'm concerned the mutation may be taking place. The children seem to me to be getting
much more sicker than they used to be one or two months ago," said Dr. Norris Payne, a Houston pediatrician.

He's seeing three or four new cases of swine flu each day.

Dr. Payne is the pediatrician for FOX 26 anchor Melissa Wilson's two year old son. Melissa's son has been diagnosed with swine flu.

Over the weekend, she says, "He was belligerent. He would not stop crying." His fever had soared to 105 degrees.

"Flu season is over, but this is the first time in 30 years I've seen flu in the summer," said Dr. Payne.

For now, the antiviral tamiflu still seems to be working.

Melissa says, "If you have a child with a fever in the middle of summer, that's odd. I would get help immediately."

Dr. Payne believes the cases he's seeing could be just the tip of the iceberg. The CDC estimates more than a million Americans have been infected
with the virus, though many probably had a mild illness.

A vaccine is still being developed but could become available sometime in the fall.

The Rhode Island Department of Health (HEALTH) today announces the second death in Rhode Island that is linked to infection of H1N1 virus. The
person, an adult woman from Providence County, had underlying medical conditions that increased her risk for serious illness from influenza.

“Sadly, we have confirmed the second death of a Rhode Island resident from illness associated with H1N1,” said Director of Health David R.
Gifford, MD, MPH. “We express our sympathies to her family and friends. This is a reminder that H1N1 is in Rhode Island and continues to spread.
Most cases we are seeing in Rhode Island are mild illness; however, anyone with underlying medical conditions such as heart or lung disease, diabetes,
immunosuppression or pregnancy can have more severe symptoms or can die.”

We have seen 58 hospitalizations and two deaths so far in Rhode Island.

SAN DIEGO -- A 50-year-old woman has become the fourth person in the San Diego area whose death is associated with the H1N1 virus, commonly known
as swine flu, the county Health and Human Services Agency reported Tuesday.

The victim's identity and details of her illness were not immediately available.

"This is an unfortunate incident," county Public Health Officer Wilma Wooten said in a statement. "Our thoughts are with the friends and family of
this individual."

Wooten said it was "particularly important" for people with "underlying medical conditions" to promptly seek treatment from a physician if they
experience flu symptoms.

A seven-year-old boy who caught the type-A (H1N1) influenza virus has become the country's first flu patient with potentially life-threatening
meningitis.

"The virus has destroyed many areas in his brain," Dr Tawee Chotepitayasunon, head of the Public Health Ministry's influenza academic team, said
yesterday.

The boy appeared convulsive on the day he was admitted to Children's Hospital last week and was given the antiviral drug oseltamivir, Tawee said.

The boy is now free of the viral infection, but the membranes enveloping his brain remain inflamed.

The condition can rapidly progress to permanent brain damage, neurological problems or even death.

The boy now is in a critical condition and being kept in a disinfected unit but can breath without the help of a respirator.

Inflammation of brain membranes in patients with the new flu virus can also occur in patients with seasonal flu, but this is rare.

Medical Service Department director-general Dr Rewat Wisarutwej said the type-A (H1N1) virus generally spread to the lungs and caused pneumonia but
that there was a possibility it could infect the brain.

Tawee cited US records that only four type-A (H1N1) patients had been reported there as also suffering from meningitis.

He urged doctors to watch patients closely, especially children with convulsive conditions, as they might be infected with the new flu virus.

"Doctors should consider providing influenza diagnostic tests for patients with convulsive conditions and high fever, because they could also be have
flulike symptoms from the outbreak of the new (H1N1) strain," he said.

People experiencing high fever for two or three days should seek medical treatment at a hospital immediately, he said.

A 20-year old woman was under close observation yesterday in a Bangkok hospital with two risk factors. She is now 12 weeks pregnant and suffering from
pre-existing medical conditions, including thalassemia. She was pale and fatigued but had a lower fever.

"We believe if her medical condition is sustained, her baby will be safe," Rewat said.

The ministry is now reporting 10 fatalities and 156 new cases, of which 82 per cent are students. Of the total of 2,428 victims, 2,381 have recovered,
and only 38 remain hospitalised.

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